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Summer Camps Mail In Registration Form

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Use BLOCK LETTERS to complete all requested information fields below.
Check all appropriate boxes.

Mail form to PSA, PMB #405, 1484 Pollard Avenue, Los Gatos, CA 95032

   
PLAYER NAME:  
ADDRESS:  
PLAYER AGE:     GENDER:     HOME PHONE:  
CONTACT EMAIL:  
 
CHECK DATE(S): June 16 - 20 at APJCC
  CHECK COST(S): $159 Open Registration    
  June 23 - 27 at APJCC     $139 APJCC Members    
. Aug 11 -15 at APJCC     $109 PSA Members    
  Aug 18 - 22 at Loma Prieta            
                 
                 
                 
                     
PAYMENT TYPE: VISA MC AMEX DISC CHECK (Payable to PSA, No Cash)

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NAME ON CARD:  
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CARD NUMBER:     EXP. DATE (mo/year):  
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BILLING ADDRESS :  
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Please contact Coach Mike with any questions.

(408) 378 - 3893
coachmikesoccer@yahoo.com
 
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